WHEN THE HELPERS NEED A HAND

Researcher Carol Morgan expected to find a different picture
when she looked at her data on family caregivers. "I had this image
of a 73-year-old woman, beaten down, pathetic," says Morgan,
president of Strategic Directions Group in St. Paul, Minnesota, a
marketing and consulting firm that surveys Americans 40 and older.
Instead, a very different portrait emerged: many of the people who
care for ailing family members or friends are busy, capable
individuals with financial resources and an upbeat outlook.
"Pathetic" is not a word that fits the profile, Morgan says.

Until recently, public interest in who's looking after Mom and
Dad was limited. The activity was seen largely as a private
commitment-family members and friends offering an array of support
ranging from housing to financial aid to home-cooked meals. But
such attitudes have begun to change. Large numbers of working women
(who still bear the brunt of these responsibilities), extended
families that have become increasingly far-flung, and an increasing
awareness of the difficulty and expense of caring for the elderly
have all contributed to turning this into a very public issue.

Currently some 22 million households with a telephone nationwide
have at least one person caring for a relative or friend, triple
the number in 1988, according to the "Family Caregiving in the
U.S." report released last year by the National Alliance for
Caregiving and the American Association of Retired Persons
(NAC/AARP). With the glut of boomers on track for retirement in the
next decade, the numbers are set to explode again, and the impact
is being felt at every level of society.

LEAVE EARLY, COME IN LATE Loss of employee time due to
family-care responsibilities has turned caregiving into a
front-and-center issue in the workplace. After all, the cost of
this lost employee productivity for American businesses is
"conservatively estimated" at $11.4 billion annually, according to
a 1997 survey by the Metropolitan Life Insurance Company. This
statistic is supported by the NAC/AARP report, which found that 49
percent of caregivers said their responsibilities forced them to
make some adjustments to their daily work schedule. Those changes
included going to work late, leaving early, or taking time off
during the day, according to the survey.

Mindful of how family responsibilities have affected the way
workers do their jobs, some employers have begun to include
coverage for such duties in their corporate benefits packages.
Businesses that address the needs of caretakers and their loved
ones will find an expanding base of customers as the number of
older Americans grows.

Information from the NAC/AARP survey offers a rich and detailed
analysis of who is taking on the job of caregiver, and what exactly
their jobs entail. Some are dutiful sons and daughters helping
their aging but alert parents with their bills and grocery shopping
several hours a week. Others are husbands or wives who spend nearly
all their waking hours caring for a spouse with Alzheimer's
disease.

Women are far more likely than men to care for others: they make
up 73 percent of caregivers. Nearly two out of three caregivers, 64
percent, are employed, while 16 percent say they are retired and 20
percent say they are unemployed.

Race also makes a difference in the likelihood of being a
caregiver. Asian and black households are more likely to include
caregivers than Hispanic or white households, the survey found. A
total of 31.7 percent of Asian households include a caregiver,
while 29.4 percent of Black households, 26.8 percent of Hispanic
households, and 24 percent of white households claim one.

Gail Hunt, executive director of the National Alliance for
Caregiving, says the reasons for some racial differences emerged in
focus groups held before and after the survey. For example, Hunt
explains, "There was a strong sense in theblack community that 'we
have always taken care of our own.' "

The income of caregivers also varies, the survey shows. The
median household income for caregivers is $35,000 per year, with
families earning $75,000 or more annually making up 10.9 percent,
and families earning under $15,000, 14 percent of the total. But
while many caregivers might not have high incomes, their consistent
spending on related expenses suggests their potential clout as
consumers. Survey respondents who kept track of their spending laid
out an average of $171 per month-totaling about $1.5 billion-on
everything from bed linens to aspirin to books about Alzheimer's
disease.

NEVER TOO BUSY TO HELD OUT Carol Morgan's psychographic research
suggests caregiving attracts take-charge, responsible, high-energy
people. "It's like the old saying," Morgan notes. "If you want to
get something done, go to a busy person." For her company's report,
Morgan and her partner, Doran Levy, defined caregivers as people
who provide help with such services as bill-paying and finances,
assistance with medical matters and emotional support. Their data
suggests that caregivers are realistic and capable of planning for
the future. "When it comes to a choice between taking Dad to the
urologist or going to the beach, [these people] would do what has
to be done and feel all right about it," Morgan says.

Yet caregivers in the survey are not only motivated by wanting
to "do the right thing." Some are thinking about their inheritance.
Caregivers are more likely to be counting on an inheritance than
noncaregivers, Morgan says, and they are also more likely to have
purchased investments from a financial planner or a bank officer,
and services from insurance agents. "The importance of this is that
caregiving is linked for many with an inheritance," says Morgan.
"If financial advisers are looking at those who inherit as a target
for products and services, they should be looking at caregivers."
Some companies already are. The marketing branch of Equitable Life
Assurance Society in New York City, for example, now offers an
investment seminar for baby boomers that focusses on caring for
their aged parents.

Morgan and Levy also found that caregiving varies dramatically
by region. Southerners are most likely to provide caregiving, with
40 percent of the population providing two or more caregiving
services. Westerners were least likely to provide such services,
with only 15 percent providing two or more services. One
explanation for this regional difference is the far younger
population of the West (19 percent of the Western population is 40
and over, compared to 35 percent of the South). Morgan said other
reasons may have to do with the more stable, family-oriented
population of the South, compared to the more transient, uprooted,
individualistic "do your own thing" aspect of Western life.
"Certainly, caring for an elderly relative could interfere with
that goal," Morgan observes.

Morgan also found a surprising characteristic of caregivers in
her study: they are a mobile group. While only 36 percent of
noncaregivers had taken a vacation lasting 10 days or more in the
previous year, 44 percent of caregivers providing two or more
services to a friend or family member had taken such a trip.

THEY DESERVE A BREAK The image of on-the-go, active caregivers
portrayed in Morgan's study contrasts with the one described in a
1996 study of 500 caregivers by the Chicago-based Alzheimer's
Association. This probably stems from the tremendous amount of time
needed to care for someone with Alzheimer's, a progressive,
degenerative brain condition that leads to almost complete
dependence on others. Caregivers of individuals with the disease
spent an average of 69 to 100 hours per week providing care for
their family member or friend, the study found. Three-quarters of
caregivers in the survey said they were depressed, and half
reported living with their ailing friend or family member, making
theirs a round-the-clock job.

The demands on these caregivers are great, says Beth
Smith-Boivin of the Alzheimer's Association. "Caring for someone
with Alzheimer's disease is a 36-hour day . Because there are so
many changes that happen with Alzheimer'ss disease-the wandering,
the sleep-cycle problems-caregivers don't get the rest they need.
People feel they can't leave for an hour."

The greatest need for most caregivers is rest, experts say, and
many businesses have sprung up to offer nonmedical services,
products and support. In addition, many nursing homes and
assisted-living facilities have set aside a small number of beds
where people with Alzheimer's and other problems can go for a
couple of days while their caregivers get a break. The market for
such services is great, given that an estimated 4 million American
adults suffer from Alzheimer's. But such services will not be used
extensively until respite is covered by public and private
insurance, Smith-Boivin notes. Many people continue to pay for
respite care out of their own savings, she says. "For fixed-income
people that's a huge issue."

Adult day care is another increasingly common option, but
relatively few caregivers know about this and other services that
may be available for them, says Hunt of the National Alliance for
Caregiving. They are in critical need of information and resources
about what's going to happen over the course of an illness, what to
expect, and what they can provide, Hunt says. "It's amazing the
little amount of information that health care professionals
typically share on those topics."

Some public agencies have reached out to educate caregivers.
Gail Norton is an in-home trainer for the Area Agency on Aging of
Broward County, Florida. Norton advises caregivers on how to make
their homes safer and how to connect with programs such as Meals on
Wheels. Norton also occasionally serves as an advocate on their
behalf with physicians. She says that often caregivers are
desperate by the time they or a neighbor call her office. "They
need education. They need training. They're losing themselves in
this and they're depressed."

The mobility of Americans presents particular challenges for
caregivers. About 6 percent of the respondents in the Family
Caregiving survey said they were long-distance caregivers. "There
are special concerns these people have," says Hunt.

Many companies are taking advantage of the need to have someone
near an elderly or ailing family member or friend to act as an
informed advocate. One such program is Genesis ElderCare in Kennett
Square, Pennsylvania, which markets its services specifically to
caregivers with careers and families. "People always think seniors
are the audience for these products, but they're not," says Sandy
Hillman, a spokesperson for Genesis. "Seniors never think they need
them." The company offers assessment services to evaluate what an
older adult needs to live independently, as well as monthly care
services. The assessment costs $225, and monthly care starts at $65
per month.

As the population ages, Hillman and others expect the need for
their services to increase. "Right now the primary market is for
children [of the elderly]," she says. "I think employers will
become the next purchasers of these products."

Whether employer support increases or fails to materialize,
there is no doubt that there will be a powerful need for care of
the elderly in the future. Businesses that provide information,
products, respite and support services for caregivers will find an
expanding market.

Eighty-three-year-old Victor Guccione is coming to grips with
his long-term health needs. When his wife died three years ago, he
vowed to remain independent. He learned to cook and shop, renewed
his driver's license and provided for himself as his wife once had.
He wintered in Florida, kept his cholesterol down and enjoyed daily
walks. All so he could stay in his New Rochelle, New York, home of
42 years.

But recently, Victor had a stroke. Now he's receiving inpatient
therapy and he's enlisted his daughter Roseanne's help in his quest
to resume life at home. Guccione knows he'll need assistance,
particularly with household chores like cooking, laundry, driving
and house cleaning.

Seniors who want to remain independent are a growing population.
Patients obtain care in their homes, both because they prefer to
and because they can afford to, thanks in large part to technology
and financial planning. A 1996 survey by the American Association
of Retired Persons (AARP) and a five-year research project in the
late 1980s by Friends Life Care at Home, a "retirement community
without walls" in Blue Bell, Pennsylvania, reveal a strong
preference among the elderly to stay at home for as long as
possible.

"Seniors don't want to be institutionalized because of the
stigma, the notion that they are old and frail," says Leon Harper,
senior program specialist for housing at AARP. "Seniors need
services that allow them to remain independent and accept their
aging process gradually. As the aging cohort increases so will the
need for nonmedical home care."

Between 1965 and 1995, the population of Americans 65 and older
increased 82 percent, peaking between 1980 and 1995, when this
segment grew to 33.5 million people. By 2050, according to the U.S.
Census Bureau, the elderly population will more than double. The
most rapid population growth rates for this age bracket are
expected to occur between the years 2010 and 2030, as the baby boom
generation reaches age 65. The elderly population is projected to
increase to 80 million people. By the year 2050, an estimated one
in five Americans will be elderly.

The Administration on Aging (AOA) projects that by the year 2020
a total of 15.22 million people over 65 will be living alone and
that 19.2 percent of them will be limited in their ability to
perform activities of daily living (ADL). Moreover, the AOA study
suggests that as the population ages, the elderlies' need for
assistance with ADLs will further increase.

These providers assist the elderly in their own homes with
fundamental and essential activities of daily life, such as light
housekeeping, meal planning and preparation, transportation, and
shopping assistance. Home-care workers also help their clients with
personal care, including dressing, bathing and simple health-care
tasks such as oral hygiene, grooming and assistance with
self-administration of medications.

Statistics on outlays are sketchy, since spending data combines
skilled nursing and nonmedical home care. A 1997 National
Association for Home Care report notes that in 1995, the total cost
of domestic personal health-care services totaled $878.8 billion.
An estimated 4 percent, or $35.15 billion, went toward home
health-care services alone. Almost half of that was paid for
through Medicare dollars, about 25 percent through Medicaid, almost
4 percent by private insurance and 22.8 percent was paid out of
pocket by consumers. Skilled nursing services were generally paid
for with Medicare and Medicaid dollars, as was nonmedical home care
provided in conjunction with skilled nursing services.

Nonmedical home care provided as a stand-alone service tends to
come right out of consumers' pocketbooks and amounts to about $8
billion a year. Home-care-industry cost estimates were projected at
$42 billion in 1997, a 20 percent or $7 billion increase from 1995
estimates. It is likely that nonmedical home-care expenditures are
on the same pace, according to Jim Fowler, vice president of
franchise development for Home Instead Senior Care, a nationwide
nonmedical home-care provider. Fowler estimates that their average
client spends approximately $10,000 a year on services.

A survey cosponsored by the National Council on Aging and the
Pew Charitable Trust found that nearly 7 million Americans provide
long-distance care (at least one hour away) to relatives and
friends aged 55 and older. Caregivers cite personal-care assistance
and companionship as two of their unmet needs. The survey predicts
that the roughly 3.3 million baby boomers now providing
long-distance care will more than double over the next 15
years.

"The nonmedical home-care market is, in part, taking over the
informal caregiving role of the family," says Meredith Patterson,
an eldercare consultant in Concord, Massachusetts, and a board
director of the National Association of Professional Geriatric Care
Managers. "With more and more children at a distance or living
their own lives at 180 miles per hour, the industry settled right
in. I won't be surprised if this trend continues."

This year, Nebraska-based Home Instead Senior Care was
identified by Entrepreneur magazine as one of the fastest-growing
franchises in the United States. It now operates 140 franchises in
33 states. SpecialCare, a provider in Kennett Square, Pennsylvania,
presently controls 44 franchises and is expanding. Smaller
providers are multiplying their sites and services.

As demand increases, the supply of nonmedical home care
providers is being directed by state regulations. According to
insiders, the industry will likely diversify, favoring players who
are hooked into the political pipeline and understand reimbursement
issues as local providers fall by the wayside.

They work mostly behind the scenes, in bedrooms and bathrooms
and living rooms. But while home-health workers toil in small
places, there is nothing small about the home-health industry.

Between 1989 and 1996, the number of home-health agencies nearly
doubled, from 11,097 to 20,215, according to the National
Association for Home Care. This increase has been accompanied by
more spending on home-health services to provide care for everyone
from elderly heart disease patients to children receiving
intravenous medicine at home.

While there are no exact figures, the National Association for
Home Care estimated in 1997 that annual spending on home care
exceeded $42 billion. One reason precise figures are difficult to
gather is because about one-fourth of all home-care dollars are
out-of-pocket expenses. Such spending is not always reported or
accounted for by statisticians.

The growth in the home-care industry suggests that home health
care is worth considering by marketers of products of a range of
products, from bed sheets to transportation services for
home-health aides. The portrait of the home-care industry sketched
by its national association is one of dynamic growth with
continuing challenges. Private and not-for-profit agencies in the
industry have long grappled with problems linked to low
reimbursement rates for home-care services. The industry also
continues to struggle with government efforts to restrict home-care
benefits.

The home-care industry has grown substantially since 1965, when
Medicare, the federal health program for older Americans, began
paying for home-care services. That year, Medicare paid $46 million
for home-care services. By 1997, Medicare coverage had ballooned to
$20.5 billion, according to the National Association for Home
Care.

Other government funding also pays for a large chunk of
home-health bills. In 1995, about 25 percent, or one in four
home-care dollars, was paid by Medicaid, the government insurance
program for poor and some disabled Americans. About 23 percent of
all home-care bills was paid out of pocket, while private insurance
paid only about 4 percent of all bills.

Because the government plays such a large role in paying for
home-care services, much of the industry depends on government
rates for reimbursement. Typically these rates have been low,
creating problems for the industry providers. For example, while
the average cost of a home-care visit was $77 in 1997, Medicare's
average benefit payment was $67 that year, according to the
National Association for Home Care.

As the population ages, experts predict that the home- care
industry will increase in size. One sign of this is that the
federal Bureau of Labor Statistics has identified "home-health
aide" as one of the jobs with the largest anticipated growth in the
1990s and early 2000s. The number of home-health aides employed is
expected to increase about 138 percent between 1992 and 2005, from
347,000 to 827,000. As the number of aides increases, so too will
the number of home-care workers in general. In 1997, the industry
employed 666,000 people, including nurses, administrators,
therapists and homemakers, according to the National Assocation for
Home Care. While home-care workers are likely to continue to carry
out their duties in small spaces , the future for the industry
looks large.